Dermatophytosis and its risk factors among children visiting dermatology clinic in Hawassa Sidama, Ethiopia

Dermatophytosis represents one of the common fungal diseases that attack the skin, hair and nail of human beings worldwide. It causes chronic morbidity in children and the condition is more common, in developing countries. The study aimed to determine dermatophytosis and its associated factors among children in Hawassa Sidama, Ethiopia April 2021–October 2021. A cross-sectional study was conducted on children suspected of cutaneous fungal infections. Data were surveyed based on a semi-structured questionnaire. Standard laboratory methods were used to identify the dermatophytes. The data entry and analysis were conducted with SPSS version 26. The Chi-square test was used to check the predictor and a p-value < 0.05 was taken as a significant value. A total of 83 study subjects included in the study in which all 83 (100%) patients were positive for fungal elements (hyphae/and spores) in microscopy, of this 81 (97.6%) yielded growth on culture. Hair scalps 75 (90.4%) were the dominant among the case. Trichophyton 52 (62.6%) was the dominant aetiology followed by Microsporum 22 (26.6%). Intervention measures to tackle dermatophytosis should emphasis on tinea capitis among 6–10 years old children with history of recent migration by raising awareness of communities through health extension programs.

Eligibility criteria. Children clinically suspected of dermatophytosis, who were attending the two facilities during the study period and whose parents consented to participate in the study were included. Children whose parents were not willing to participate, and who had received oral or topical antifungal treatment within the previous two weeks were excluded from the study.

Data collection procedures.
During the visit to the dermatology clinic, the attending clinician/nurse along with the investigator explained the objective of the study to each patient or parent/caretaker and written formal consent was secured. After that, the questionnaire was administered through face-to-face interview with the caregiver.
Collection of dermatological specimens. The dermatological sample collections were based on a standard practical guide and atlas for the diagnosis of fungal infections 13 . Briefly, after cleaning the area of the lesion on the skin with 70% ethanol, samples were taken from the erythematous, peripheral and actively growing margins of the skin lesions hair and nail by scraping with a blunt scalpel blade by trained laboratory technologists and clinical nurses. The specimens were then, transferred into a sterile Petri dish, and labelled with the patient's Microbiological laboratory analysis. Microbiological laboratory analysis was based on the study Nagar, S.N., Diagnosis of dermatophytosis 14 . Each sample was treated with 1-2 drops of 10% KOH solution for 15-30 min and microscopically examined for the presence of fungal elements (spore and hyphae) under a light microscope at 10 × and 40 × magnification power. Portions of the specimens were aseptically inoculated on plates of Sabouraud's Dextrose agar (SDA)and incubated at room temperature (22-25°°C). The SDA platecultures were periodically examined for growth of dermatophytes every other day for four weeks and positive cultures were examined macroscopically for species identification based on Colony characteristics (macroscopic)-Gross colony features observed on SDA include the colour of the surface, the colour of reverse, the texture of the surface (powdery, granular, velvety, or fluffy) type of folding (radial, cerebriform), and the rate of growth 13 . Data management and quality assurance. Media were checked for growth of non-dermatophytes by incubating at 25 °C for four weeks. Phenotypic identification of fungal isolates was done by a panel of experienced laboratory technologists (three) and a colour atlas of medical mycology. www.nature.com/scientificreports/ Data processing and analysis. All data were coded and entered into logbooks and then into the computer and were analyzed using IBM SPSS Statistics for Windows Version 26.0 (IBM Corp., Armonk, NY, USA). In the descriptive study, categorical variables were represented as the mean ± standard deviation (SD), and qualitative variables were expressed as relative frequencies and percent. The Chi-square test was used to compare the prevalence among the independent variables. A p-value of < 0.05 was considered tohave statistical significance.    www.nature.com/scientificreports/ Ethical consideration. Ethical clearance was obtained from the Institutional Review Board (IRB) Department of Medical Laboratory Science, College of Health Sciences Hawassa University. Permission was also obtained from Hawassa university comprehensive specialized Hospital and Dr Girum Medium Clinic. Parents or guardians signed a consent form after being informed of the objectives of the study and the confidentiality of participants' personal information was protected as rights to refuse to take part in the study as well as to withdraw at any time during the study period were given. All the information obtained from the study patients was coded to maintain confidentially. When the participants were found positive for dermatophytosis they were reported to the hospital and the clinician treated them accordingly. All methods were performed following the relevant guidelines and regulations.

Result
Sociodemographic characteristics of study participants. In  Behavioural and environmental factors among the study patients. The majority (68.7%) of the study participants were within the family size of 4-6. The peak season of the onset of dermatophyte infection among the study participants was kiremt (Major rainy season, June to September) 44 (53%) followed by Belg (the hot humid/second rainy season, April and May) 33 (39.8%) and Bega/winter (October) season 6 (7.2%) ( Table 1). In most of the study participant's home 73 (88%), there were no similar cases with patients. On the other hand, 62 (74.7%) said they came from another place (migrant), and 72 (86.7%) kept dogs and cats. The majority of patients shared bathrooms 79 (95.2%) and 58(69.9%) said they did not walk on barefoot ( Table 1).

The dermatophytosis and site of infection.
Of the total of 83 study participants dermatological specimens 75 (90.36%) were hair/scalp, and 4 (4.82%) each were skin and nail samples. All of the 83 (100%) samples were positive with KOH wet mount showing fungal hyphal elements/and spores under a light microscope. And 81 (97.59%) of the specimens showed colonial growth of dermatophytes on SDA in between 1 and 4 weeks of incubation.
The etiological agents of dermatophytosis. Based on microscopic KOH wet mount and colonial morphology of culture the etiological agents for 81 of the cases were putatively identified into three genera of dermatophytes. Accordingly, the dominant genera were Trichophyton 52/83 (62.6%), Microsporum 22/83 (26.5%) and Epidermophyton 7/83 (8.5%). Two of the specimens did not yield growth on SDA despite the observed fungal hyphal elements on KOH microscopic mount ( Table 2, Fig. 4). www.nature.com/scientificreports/ p = 0.00) and history of migration from rural to urban (χ 2 = 6.05, df = 1, p = 0.01) and site of infection (χ 2 = 9.14, df = ,p = 0.01) were the only two risk factors found to be associated with dermatophytosis (Table 1).

Discussion
In our study 83 clinically suspected patients of cutaneous mycosis were included and skin, hair and nail samples were obtained during the study period. The direct KOH mount microscopic examination of clinical specimens showed that all of the study participants (83/83 or 100%) were positive for dermatophytosis. However, the culture of the specimens on SDA showed growth only for 81 (97.6%) of the patients. Due to a lack of supply for staining and facility for molecular further identification to species level was not conducted. In agreement with the present observation, a higher detection yield of dermatophytosis by the KOH mount and microscopy than culture on SDA was reported in a study done in India where all the specimens from 165 study subjects (100%) were KOH positive while only 67.1% of them were culture positive 9   www.nature.com/scientificreports/ while 100 (76%) were culture positive 15 . In contrast, a study done in Iraq revealed that of 100 dermatological specimens investigated, 84% were KOH-positive while 93% were culture-positive 15 . Unlike, the report from Iraq, in the present study, the KOH mount and microscopy yielded a higher detection level than that from culture on SDA. These slight variations among the different studies might be due to differences in the Geographic location, living standards, culture, sample size and collecting site. It is widely accepted that low socio-economic status associated with large families in crowded living conditions, and poor hygiene, are associated with increased prevalence of dermatophytosis 16 .
In the present study, Tinea capitis was the main clinical manifestation agreeing with a study on African children 17 . A study in Egypt reported Tinea capitis (85.2%) followed by Tinea corporis (8.1%) and Tinea unguium (6.7%) in order were the most frequent cases 18 . This is concordant with our study. Tinea capitis is an infection of scalp hair follicles and the surrounding skin caused by dermatophyte fungi, usually by Microsporum (ectothrix) and Trichophyton (endothrix) and its clinical presentation are highly variable, depending on the causative organism, type of hair invasion, degree of host inflammatory response 19 . It is a type of dermatophytosis presentation most commonly seen in children [20][21][22] and the data in the present study is, therefore, in agreement with this general norm. Although dermatophyte infection of the general body surface, tinea corporis is also known to be fairly common in children, it constituted a minor observation in the present study. On the other hand, nail infection (onychomycosis or Tinea unguium) is unusual during the first two decades of life, with a prevalence of less than 1% that increases progressively with age 22 . The data in the present study is concordant with the above observation.
The etiological agents of tinea capitis are known to exhibit successional changes over time and geographical region. For example, in the 1960 and 1970s, the less severe and transmissible Microsporum species were the dominant species that caused infection of the scalp in North America. It is now replaced by the rising dominant species of Trichophyton tonsurans, which is the most common cause of tinea capitis in the region. T. tonsurans has also been reported to be on the rise in urban areas of London, UK 23 , and Parisian areas in France 23 . In Africa, other Trichophyton species like T. Verrucosum and T. violaceum are the more common causes of tinea capitis than T. tonsurans 20 . A study done in Uganda based on 115 patients aged 1-16 years, reported T. violaceum (56.6%) as the most common cause of tinea capitis followed by Microsporum audouinii (13%) 24 . Unlike the general geographic distribution of the species reported before, Trichophyton genera were the predominant species of dermatophyte isolated from hair/scalp samples in the present study. Being strictly general is subject to wide distribution following human migration. It has been observed that T. rubrum and T. tonsurans, are now cosmopolitan but appear to have had a more restricted distribution in the past, having been transported widely as a result of human migration 21 .
In agreement with the present study, a study from Kenya reported T. tonsurans under the genera of Trichophyton was the predominant cause of tinea capitis 25 . Trichophyton has never been reported as a predominant cause of tinea capitis in children in Ethiopia before. In a similar study done in Tikur Anbessa Teaching Hospital, Addis Ababa, Ethiopia based on samples from 305 children investigated, T. violaceum, T. mentagrophytes and M. canis in order were the reported dominant dermatophytes that caused tinea capitis 9 . Another study done in Harari Regional State of Ethiopia reported T. rubrum, M. audouinii, T. violaceum T. mentagrophytes, E. floccosum, and M. canis in order were the predominant causes of tinea capitis in children 26 .
In contrast with the present study, the majority of the studies done in Africa reported a preponderance of dermatophytosis in male than female children 17 . A few studies done in Ethiopia also reported dermatophytosis is more in male than female children. A study in the Harari region of Ethiopia reported that of the 100 dermatophytosis culture-positive school children, the majority were males (52%) and 48% females 26 . Tinea capitis was the predominant presentation and T. violaceum and T. rubrum in order were the most frequent isolates from both sexes. In another study done in Ethiopia, Woldeamanuel et al. also reported dermatophytosis more in male than female children 27 . One study done among 428 school children in Harari Regional State of Ethiopia, reported that 100 (23.4%) of them had culture-confirmed dermatophytosis of which tinea capitis accounted for 77 of them the major causative agents were T. violaceum (43/77 or 55.84%) and T. rubrum (24/77 or 31.17%) under genera of Trichophyton. The majority of culture-confirmed cases were in the age group of 10-14 years (62%) while 38% were in the age group of 5-9 years old. The present study is slightly in contrast with the report from the Harari region in that younger age groups (less than 10 years old) were the most affected 26 . A study done in Nairobi Kenya reported the isolation of dermatophytes from 150 samples and the most frequent cases were among 9-11 years Table 3. Distribution of putatively identified dermatophytes by age &sex of children visiting dermatology clinics in Hawassa (n = 83).

Epidermophyton (%) Microsporum (%) Trichophyton (%) No growth (%)
Age (years) www.nature.com/scientificreports/ patients followed by the age group of 6-8 years and ages groups of 12-14 and 3-5 years. Precise comparison is difficult since age grouping differed among the studies. But again this report from Kenya may be considered concordant with the present observation in that patients younger than 10 years old were the most affected 19 . A similar study in Nigeria based on an investigation of 100 samples reported that dermatophytosis was most frequent among the age group of 11-15 years (50%) old followed by that of 5-10 years (42.6%) old study patients 28 .
Another study from Nigeria also reported that the majority of the children with dermatophytosis in their study were in the age group below 10 years 41(83.7%) 29 .
In agreement with the present study, the predominance of dermatophytosis is more in females than males among school children in reported in Alexandria, Egypt 30 . Likewise, a study done in Brazil among 590 children in the age group of 12 years and under, investigated dermatophytosis by the culture of the different specimens. The study revealed that 210 of the samples were positive consisting of 125 (59.52%) females and 85 (40.48%) males. The majority of the cases were tinea capitis (153) followed by Tinea corporis (48) and Tinea pedis (6). The principal causative agents of Tinea capitis were T. tonsurans (121/153 or 79.1%) and M. canis (24/153 or 15.69%) 31 . The observed variation in the incidence of dermatophytosis by sex among the different studies might be due to differences in culture, and religion, among the study populations.
There was a statistical association between dermatophytosis incidence and the age of children, site of infection and migration from rural to urban (p < 0.05). A similar study done in Harari Regional State of Ethiopia reported observation in agreement with this study 26 . A similar study from the Netherlands also reported an association of dermatophytosis with rural-to-urban migration 32 . Likewise, a study in California reported the most important predictor of Tinea capitis is migration and the most likely site of infection was hair/ scalp in children 28 .

Limitations of the study
In the present study confirmation of species by observation of micro-and macroconidia was not possible due to a lack of reagents and facilities like lactophenol cotton blue stain and molecular identification tools. Besides this, this study can't confer the whole situation in the area as it is a cross-sectional study.

Conclusion
The KOH mount and microscopic examination of dermatological specimens yielded a higher number of cases than the culture method in the present study. However, the culture method has the added advantage of observation of colonial morphology and putative identification of the etiological agent with the help of a standard colour atlas. Therefore, the use of both methods is recommended in the diagnosis of dermatophytosis and further study with a large population with advanced testing is recommended in future by using these findings as a baseline to determine the burden of dermatophytes in different populations.

Data availability
The datasets used and/or analyzed during the current study are available from the corresponding and main author upon reasonable request.